Navarro-Illana et al. BMC Public Health 2014, 14:490 http://www.biomedcentral.com/1471-2458/14/490
RESEARCH ARTICLE
Open Access
“Knowledge and attitudes of Spanish adolescent girls towards human papillomavirus infection: where to intervene to improve vaccination coverage” Pedro Navarro-Illana1*, Javier Diez-Domingo2, Esther Navarro-Illana1, José Tuells4, Sara Alemán3 and Joan Puig-Barberá3
Abstract Background: HPV vaccine coverage is far from ideal in Valencia, Spain, and this could be partially related to the low knowledge about the disease and the vaccine, therefore we assessed these, as well as the attitude towards vaccination in adolescent girls, and tried to identify independently associated factors that could potentially be modified by an intervention in order to increase vaccine coverage. Methods: A cross sectional study was conducted in a random selection of schools of the Spanish region of Valencia. We asked mothers of 1278 girls, who should have been vaccinated in the 2011 campaign, for informed consent. Those that accepted their daughters’ participation, a questionnaire regarding the Knowledge of HPV infection and vaccine was passed to the girls in the school. Results: 833 mothers (65.1%) accepted participation. All their daughters’ responded the questionnaire. Of those, 89.9% had heard about HPV and they associated it to cervical cancer. Only 14% related it to other problems like genital warts. The knowledge score of the girls who had heard about HPV was 6.1/10. Knowledge was unrelated to the number of contacts with the health system (Pediatrician or nurse), and positively correlated with the discussions with classmates about the vaccine. Adolescents Spanish in origin or with an older sister vaccinated, had higher punctuation. 67% of the girls thought that the vaccine prevented cancer, and 22.6% felt that although prevented cancer the vaccine had important safety problems. 6.4% of the girls rejected the vaccine for safety problems or for not considering themselves at risk of infection. 71.5% of the girls had received at least one vaccine dose. Vaccinated girls scored higher knowledge (p = 0.05). Conclusion: Knowledge about HPV infection and vaccine was fair in adolescents of Valencia, and is independent to the number of contacts with the health system, it is however correlated to the conversations about the vaccine with their peers and the vaccination status. An action to improve HPV knowledge through health providers might increase vaccine coverage in the adolescents. Keywords: Vaccines, Papillomavirus infections, Papillomavirus vaccines, Adolescent behavior, Health knowledge, Attitudes, Practice
* Correspondence: [email protected] 1 Facultad de Enfermería, Universidad Católica de Valencia “San Vicente Mártir”, C/Jesús, 10, 46007 Valencia, Spain Full list of author information is available at the end of the article © 2014 Navarro-Illana et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Navarro-Illana et al. BMC Public Health 2014, 14:490 http://www.biomedcentral.com/1471-2458/14/490
Background Chronic infection with Human Papillomavirus (HPV) is known to cause a range of pre-cancerous, cancerous and being lesions like genital warts [1]. In Spain, cervical cancer is the sixth most common malignancy, representing 4.8% of all cancers in women. However its incidence is one of the lowest worldwide (Predicted age standardized rate in 2012 of 11.6 cases per 100.000 women/year) [2] and the mortality rate of 2.7 per 100.000 women/year, similar to European average [3,4]. HPV vaccines are highly efficacious in preventing chronic infections and dysplasias by serotypes 16 and 18, the most common oncogenic types [5-8]. Routine vaccination for all girls aged 14 years is recommended in Valencia, since October 2008, and available free of cost. However, the vaccine coverage decreased since its implementation. In 2008, 85%, of the target population received at least one HPV vaccine dose, and 73,9% received all three doses. The following year coverage dropped to 66.1% for one and 63.3% for three doses. Factors that could have influenced were: lack of awareness about the infection, the impact of the media in relation to some alleged safety problems at the beginning of the vaccination program [9], and concerns about vaccine effectiveness promulgated by local critical groups [10]. It is therefore important to develop activities in order to increase the vaccine coverage. As a first step we considered to assess the knowledge about the disease and vaccine and the attitudes towards the vaccine in the target groups, so that could devise interventions directed to the weaker points. Worldwide many of the studies have examined individual awareness, knowledge and attitudes towards vaccination. Prior to the vaccine licensure, most of the studies reported as most significant a lack of knowledge, and recurrent myths, e.g. the impact of vaccination on promiscuity [11]. Subsequently, large vaccination campaigns in different countries have had a favorable impact on the perception of the vaccine to prevent disease. In the era post vaccine distribution, knowledge was positively associated with older age, higher education, number of sexual partners, previous diagnosis of cervical dysplasia or having ad an HIV test, and it was negatively associated in the United States with Latin American origin, opposition to premarital sex and certain religious beliefs [12,13]. In several studies, summarized in a systematic review there is a correlation between vaccine uptake and HPV disease and vaccine knowledge, attitudes regarding vaccination and having a healthcare provider as a source of information [14]. However [15] there is not strong evidence to recommend any specific educational intervention related to HPV vaccine for wide-spread implementation, as the quality of the trials published so far is low and in literate populations, therefore future studies are required to
Page 2 of 8
determine the effectiveness of culturally- competent interventions reaching diverse populations. In the same way, a metanalysis found that individual interventions (not during a health encounter) to inform or educate parents have a low impact on their babies vaccine coverage, although again the information is limited and of low quality, and the main recommendation was to do this communication as a complementary activity in a clinic [16]. There are few studies assessing the knowledge and attitudes of exclusively young adolescents towards vaccination. This age group is important as the primary target population for the vaccine delivery. At this age as girls become more independent, their decision to be or not vaccinated is, at least, as important as their parents’ [17]. At this age, less than 5% of the girls have had their first sexual intercourse [18], and therefore their sexual history, an important driver for higher knowledge, is less relevant. A recent report from colleges in the United Kingdom, reported a low awareness and knowledge about HPV and HPV vaccination in a cohort of girls that were offered the vaccination through a school-based program [19]. The objective of our study was to assess the knowledge and attitudes of 15 year-old Spanish girls (who were candidates to receive the vaccine) towards HPV infection and the vaccine, and to identify independently associated factors that could potentially be modified by an intervention.
Methods Design
A cross-sectional descriptive study in adolescent girls (aged 15, born in 1995) was carried out. All data was collected between September 2010 and May 2011. The girls were eligible to receive and complete the HPV vaccine series in the previous season (by June 2010). Adolescent girls were recruited from primary schools of the Province of Valencia, Spain. Schools were randomly selected depending on the population for each of the Counties of the Province, and included private and public schools. Both, mothers and girls completed an informed consent forms prior to any research activity. Investigators sent the informed consent to mothers through the school head teachers. The teachers collected the forms. Schools were paid €10 per each mother’s signed informed consent collected. Adolescents completed the study questionnaire in the school, in the presence of one person from the research team. Prior to distribution all participants received the same information, and no further comments were made after the questionnaire was handed to the girls to avoid biasing the answers. The Ethics Committee of the Center for Public Health Research (CSISP), Valencia, Spain approved the study.
Navarro-Illana et al. BMC Public Health 2014, 14:490 http://www.biomedcentral.com/1471-2458/14/490
Instrument
A questionnaire, which consisted of 38 items, was developed. It assessed demographic information, social variables, including religious affiliation and religious practice, and social status of the family as recommended by the Spanish Epidemiology Association [20]. Use of health resources included the number of times in the previous year that they had a pediatric, GP, nurse or gynecologist consultation, and whether they were followed up due to any chronic condition. Toxic consumption: smoking, cannabis, cocaine and pills could have been ‘never consumed’, ‘consumed’, ‘seldom consumed’ or ‘habitual consumption’. Awareness of social problems was quantified using 5-points Likert scales (1 = no concern to 5 = extremely concerned) in 9 questions, including terrorism, epidemics, accidents, school failure and safety. Awareness of health problems was also quantified using the same Likert scales in 9 items, asking for concern about cancer, infectious diseases (i.e. AIDS and STDs), depression, new epidemics, diseases related to alcohol or other drugs and obesity. Two scores were developed, a social awareness score and a health awareness score. Each was calculated as the mean of the punctuation of the individual items (1 to 5). HPV disease and HPV vaccine awareness were assessed by two items: ‘have you ever heard about HPV?’ and ‘have you ever heard about the HPV vaccine?’. HPV knowledge was assessed using a 16 closed ended true/false items. By HPV knowledge we are referring to the degree to which a person possesses and understands objective information pertinent to HPV. To discourage guessing by the participants, researchers instructed them to choose ‘don’t know’. Distracter items, which assessed higher level of understanding of HPV infection, were included. These included an item to rule out the connection between HPV and ovarian cancer. We also included true/ false statements (i.e. HPV produces hepatic cancer), to assess knowledge discrimination through rejection of false statements [21]. A knowledge summary score was computed by assigning one point for each correct response and zero points for each incorrect and ‘don’t know’ answers. Points were summed to create a knowledge summary score. HPV vaccine knowledge was assessed with five questions: ‘How many doses are required for a complete vaccination schedule’ and four closed ended true/false items on the effect of the vaccine on future infections, the need to use condoms, the need to follow genital screening and the effect towards cervical cancer. The means of receiving information about the vaccine was assessed with the question: ‘where have you heard about HPV vaccine?’. Attitudes towards general vaccination were assessed by a Likert scale in two questions asking about their attitudes and their friends’, and also two open questions
Page 3 of 8
asking about their beliefs regarding benefits and problems of vaccines. HPV vaccination attitude was assessed by asking the girls’ opinion about the vaccine, possible answers were: ‘it is a very good vaccine to prevent cervical cancer’, ‘it is a vaccine that prevents cervical cancer but has problems’, ‘it is a good vaccine but is painful and I am frightened’ and ‘it is a vaccine for a disease I will never get’. We also asked about the sources for vaccine information (e.g., TV, press, radio, internet, brochures/leaflets, pediatrician, nurse, parents and friends). A general summary question asked the girls to consider and select the most relevant statement about the vaccine: ‘it is a very good vaccine to prevent cervical cancer’, ‘it is a vaccine to prevent cancer but it is problematic’, ‘it is a good vaccine but I am frightened because it hurts’, ‘it is a disease I am never getting and therefore I am not receiving the vaccine’. The answer to the number of vaccine doses received was checked with the Valencian vaccine registry, concordance was very high (Kappa = 0.92). The questionnaire was piloted to validate comprehension among 15 girls in one school situated within a socioeconomic deprived area and used to validate the comprehension of the questions.
Statistical analysis
For qualitative variables, number and percentage with its normal 95% CI were calculated, with missing data included in the calculation of percentages. Non-parametric or ordinal variables were compared using the Mann– Whitney-Wilcoxon test when comparing two groups, or the Kruskal-Wallis test when comparing three or more groups. Correlations were estimated between the HPV knowledge summary score and all variables potentially related to knowledge. Pearson Product Moment Correlations were calculated to estimate the relationship between two continuous variables and Point-Biserial correlations were calculated to estimate the relationship between a dichotomous variable (e.g., provider recommendation for the HPV vaccine: yes or no) and a continuous variable (HPV knowledge). All data processing was performed using SPSS for Windows (Version 15). Questionnaire validation
Cronbach’s alpha was used to assess internal consistency of each construct of the questionnaire. When the alpha value was lower than 0.70, we considered that each of the individual questions from these constructs actually measured multiple unrelated psychological domains. Questions from these constructs were considered individually in the multivariate linear regression model of predictors of parental HPV vaccine acceptability.
Navarro-Illana et al. BMC Public Health 2014, 14:490 http://www.biomedcentral.com/1471-2458/14/490
Page 4 of 8
Results
Table 2 Social and health concerns and toxic consumption among adolescent girls in Spain
Sample
1278 mothers distributed among the schools were asked for informed consent, 833 (65.1%) accepted participation, in all those cases; their daughters fulfilled the questionnaire in the school and were included in the analysis. Eighty percent of the adolescents lived with both parents and their socioeconomic status was similar to that occurring in Spain in 2010. Most of the parents (82.5%, 95% CI: 79.9-85.1%) were Spanish in origin and 11.3% from South America. Over 85% of the girls were born in Spain (Table 1).
Adolescents’ concerns and attitudes towards social and health problems
Among the social problems that girls were concerned about, school and sport accidents were the least rated, while those more severe or with higher media impact were of highest concern: road traffic accidents and terrorist attacks (Table 2). Concerns about health problems were diverse, being the weight problems the most rated (Table 2), with 78.5% (95% CI: 75.7-81.3%) of the girls being worried about it. Table 1 Characteristics of the study participants N
%
Spain
716
86.0
Other
116
14
Country of birth
Current family status Living with both parents
658
79.0
Parents divorced/separated
138
16.5
Father or mother widow
25
3.0
Other
12
1.4
117
0.14
Religious beliefs Practising Occasional practising
133
16.0
Non-practising
303
36.4
Non-believer
215
25.8
No answer
65
7.8
Father (%)
Mother (%)
52 (6.9)
12 (1.6)
187 (24.7)
117 (15.5)
30 (4.0)
87 (11.5)
Admin./self-employed
171 (22.6)
100 (13.2)
Qualified technician
176 (23.5)
97 (12.8)
Parents occupation Unemployed Undergraduate/director >10 Postgraduate/director
RESEARCH ARTICLE
Open Access
“Knowledge and attitudes of Spanish adolescent girls towards human papillomavirus infection: where to intervene to improve vaccination coverage” Pedro Navarro-Illana1*, Javier Diez-Domingo2, Esther Navarro-Illana1, José Tuells4, Sara Alemán3 and Joan Puig-Barberá3
Abstract Background: HPV vaccine coverage is far from ideal in Valencia, Spain, and this could be partially related to the low knowledge about the disease and the vaccine, therefore we assessed these, as well as the attitude towards vaccination in adolescent girls, and tried to identify independently associated factors that could potentially be modified by an intervention in order to increase vaccine coverage. Methods: A cross sectional study was conducted in a random selection of schools of the Spanish region of Valencia. We asked mothers of 1278 girls, who should have been vaccinated in the 2011 campaign, for informed consent. Those that accepted their daughters’ participation, a questionnaire regarding the Knowledge of HPV infection and vaccine was passed to the girls in the school. Results: 833 mothers (65.1%) accepted participation. All their daughters’ responded the questionnaire. Of those, 89.9% had heard about HPV and they associated it to cervical cancer. Only 14% related it to other problems like genital warts. The knowledge score of the girls who had heard about HPV was 6.1/10. Knowledge was unrelated to the number of contacts with the health system (Pediatrician or nurse), and positively correlated with the discussions with classmates about the vaccine. Adolescents Spanish in origin or with an older sister vaccinated, had higher punctuation. 67% of the girls thought that the vaccine prevented cancer, and 22.6% felt that although prevented cancer the vaccine had important safety problems. 6.4% of the girls rejected the vaccine for safety problems or for not considering themselves at risk of infection. 71.5% of the girls had received at least one vaccine dose. Vaccinated girls scored higher knowledge (p = 0.05). Conclusion: Knowledge about HPV infection and vaccine was fair in adolescents of Valencia, and is independent to the number of contacts with the health system, it is however correlated to the conversations about the vaccine with their peers and the vaccination status. An action to improve HPV knowledge through health providers might increase vaccine coverage in the adolescents. Keywords: Vaccines, Papillomavirus infections, Papillomavirus vaccines, Adolescent behavior, Health knowledge, Attitudes, Practice
* Correspondence: [email protected] 1 Facultad de Enfermería, Universidad Católica de Valencia “San Vicente Mártir”, C/Jesús, 10, 46007 Valencia, Spain Full list of author information is available at the end of the article © 2014 Navarro-Illana et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Navarro-Illana et al. BMC Public Health 2014, 14:490 http://www.biomedcentral.com/1471-2458/14/490
Background Chronic infection with Human Papillomavirus (HPV) is known to cause a range of pre-cancerous, cancerous and being lesions like genital warts [1]. In Spain, cervical cancer is the sixth most common malignancy, representing 4.8% of all cancers in women. However its incidence is one of the lowest worldwide (Predicted age standardized rate in 2012 of 11.6 cases per 100.000 women/year) [2] and the mortality rate of 2.7 per 100.000 women/year, similar to European average [3,4]. HPV vaccines are highly efficacious in preventing chronic infections and dysplasias by serotypes 16 and 18, the most common oncogenic types [5-8]. Routine vaccination for all girls aged 14 years is recommended in Valencia, since October 2008, and available free of cost. However, the vaccine coverage decreased since its implementation. In 2008, 85%, of the target population received at least one HPV vaccine dose, and 73,9% received all three doses. The following year coverage dropped to 66.1% for one and 63.3% for three doses. Factors that could have influenced were: lack of awareness about the infection, the impact of the media in relation to some alleged safety problems at the beginning of the vaccination program [9], and concerns about vaccine effectiveness promulgated by local critical groups [10]. It is therefore important to develop activities in order to increase the vaccine coverage. As a first step we considered to assess the knowledge about the disease and vaccine and the attitudes towards the vaccine in the target groups, so that could devise interventions directed to the weaker points. Worldwide many of the studies have examined individual awareness, knowledge and attitudes towards vaccination. Prior to the vaccine licensure, most of the studies reported as most significant a lack of knowledge, and recurrent myths, e.g. the impact of vaccination on promiscuity [11]. Subsequently, large vaccination campaigns in different countries have had a favorable impact on the perception of the vaccine to prevent disease. In the era post vaccine distribution, knowledge was positively associated with older age, higher education, number of sexual partners, previous diagnosis of cervical dysplasia or having ad an HIV test, and it was negatively associated in the United States with Latin American origin, opposition to premarital sex and certain religious beliefs [12,13]. In several studies, summarized in a systematic review there is a correlation between vaccine uptake and HPV disease and vaccine knowledge, attitudes regarding vaccination and having a healthcare provider as a source of information [14]. However [15] there is not strong evidence to recommend any specific educational intervention related to HPV vaccine for wide-spread implementation, as the quality of the trials published so far is low and in literate populations, therefore future studies are required to
Page 2 of 8
determine the effectiveness of culturally- competent interventions reaching diverse populations. In the same way, a metanalysis found that individual interventions (not during a health encounter) to inform or educate parents have a low impact on their babies vaccine coverage, although again the information is limited and of low quality, and the main recommendation was to do this communication as a complementary activity in a clinic [16]. There are few studies assessing the knowledge and attitudes of exclusively young adolescents towards vaccination. This age group is important as the primary target population for the vaccine delivery. At this age as girls become more independent, their decision to be or not vaccinated is, at least, as important as their parents’ [17]. At this age, less than 5% of the girls have had their first sexual intercourse [18], and therefore their sexual history, an important driver for higher knowledge, is less relevant. A recent report from colleges in the United Kingdom, reported a low awareness and knowledge about HPV and HPV vaccination in a cohort of girls that were offered the vaccination through a school-based program [19]. The objective of our study was to assess the knowledge and attitudes of 15 year-old Spanish girls (who were candidates to receive the vaccine) towards HPV infection and the vaccine, and to identify independently associated factors that could potentially be modified by an intervention.
Methods Design
A cross-sectional descriptive study in adolescent girls (aged 15, born in 1995) was carried out. All data was collected between September 2010 and May 2011. The girls were eligible to receive and complete the HPV vaccine series in the previous season (by June 2010). Adolescent girls were recruited from primary schools of the Province of Valencia, Spain. Schools were randomly selected depending on the population for each of the Counties of the Province, and included private and public schools. Both, mothers and girls completed an informed consent forms prior to any research activity. Investigators sent the informed consent to mothers through the school head teachers. The teachers collected the forms. Schools were paid €10 per each mother’s signed informed consent collected. Adolescents completed the study questionnaire in the school, in the presence of one person from the research team. Prior to distribution all participants received the same information, and no further comments were made after the questionnaire was handed to the girls to avoid biasing the answers. The Ethics Committee of the Center for Public Health Research (CSISP), Valencia, Spain approved the study.
Navarro-Illana et al. BMC Public Health 2014, 14:490 http://www.biomedcentral.com/1471-2458/14/490
Instrument
A questionnaire, which consisted of 38 items, was developed. It assessed demographic information, social variables, including religious affiliation and religious practice, and social status of the family as recommended by the Spanish Epidemiology Association [20]. Use of health resources included the number of times in the previous year that they had a pediatric, GP, nurse or gynecologist consultation, and whether they were followed up due to any chronic condition. Toxic consumption: smoking, cannabis, cocaine and pills could have been ‘never consumed’, ‘consumed’, ‘seldom consumed’ or ‘habitual consumption’. Awareness of social problems was quantified using 5-points Likert scales (1 = no concern to 5 = extremely concerned) in 9 questions, including terrorism, epidemics, accidents, school failure and safety. Awareness of health problems was also quantified using the same Likert scales in 9 items, asking for concern about cancer, infectious diseases (i.e. AIDS and STDs), depression, new epidemics, diseases related to alcohol or other drugs and obesity. Two scores were developed, a social awareness score and a health awareness score. Each was calculated as the mean of the punctuation of the individual items (1 to 5). HPV disease and HPV vaccine awareness were assessed by two items: ‘have you ever heard about HPV?’ and ‘have you ever heard about the HPV vaccine?’. HPV knowledge was assessed using a 16 closed ended true/false items. By HPV knowledge we are referring to the degree to which a person possesses and understands objective information pertinent to HPV. To discourage guessing by the participants, researchers instructed them to choose ‘don’t know’. Distracter items, which assessed higher level of understanding of HPV infection, were included. These included an item to rule out the connection between HPV and ovarian cancer. We also included true/ false statements (i.e. HPV produces hepatic cancer), to assess knowledge discrimination through rejection of false statements [21]. A knowledge summary score was computed by assigning one point for each correct response and zero points for each incorrect and ‘don’t know’ answers. Points were summed to create a knowledge summary score. HPV vaccine knowledge was assessed with five questions: ‘How many doses are required for a complete vaccination schedule’ and four closed ended true/false items on the effect of the vaccine on future infections, the need to use condoms, the need to follow genital screening and the effect towards cervical cancer. The means of receiving information about the vaccine was assessed with the question: ‘where have you heard about HPV vaccine?’. Attitudes towards general vaccination were assessed by a Likert scale in two questions asking about their attitudes and their friends’, and also two open questions
Page 3 of 8
asking about their beliefs regarding benefits and problems of vaccines. HPV vaccination attitude was assessed by asking the girls’ opinion about the vaccine, possible answers were: ‘it is a very good vaccine to prevent cervical cancer’, ‘it is a vaccine that prevents cervical cancer but has problems’, ‘it is a good vaccine but is painful and I am frightened’ and ‘it is a vaccine for a disease I will never get’. We also asked about the sources for vaccine information (e.g., TV, press, radio, internet, brochures/leaflets, pediatrician, nurse, parents and friends). A general summary question asked the girls to consider and select the most relevant statement about the vaccine: ‘it is a very good vaccine to prevent cervical cancer’, ‘it is a vaccine to prevent cancer but it is problematic’, ‘it is a good vaccine but I am frightened because it hurts’, ‘it is a disease I am never getting and therefore I am not receiving the vaccine’. The answer to the number of vaccine doses received was checked with the Valencian vaccine registry, concordance was very high (Kappa = 0.92). The questionnaire was piloted to validate comprehension among 15 girls in one school situated within a socioeconomic deprived area and used to validate the comprehension of the questions.
Statistical analysis
For qualitative variables, number and percentage with its normal 95% CI were calculated, with missing data included in the calculation of percentages. Non-parametric or ordinal variables were compared using the Mann– Whitney-Wilcoxon test when comparing two groups, or the Kruskal-Wallis test when comparing three or more groups. Correlations were estimated between the HPV knowledge summary score and all variables potentially related to knowledge. Pearson Product Moment Correlations were calculated to estimate the relationship between two continuous variables and Point-Biserial correlations were calculated to estimate the relationship between a dichotomous variable (e.g., provider recommendation for the HPV vaccine: yes or no) and a continuous variable (HPV knowledge). All data processing was performed using SPSS for Windows (Version 15). Questionnaire validation
Cronbach’s alpha was used to assess internal consistency of each construct of the questionnaire. When the alpha value was lower than 0.70, we considered that each of the individual questions from these constructs actually measured multiple unrelated psychological domains. Questions from these constructs were considered individually in the multivariate linear regression model of predictors of parental HPV vaccine acceptability.
Navarro-Illana et al. BMC Public Health 2014, 14:490 http://www.biomedcentral.com/1471-2458/14/490
Page 4 of 8
Results
Table 2 Social and health concerns and toxic consumption among adolescent girls in Spain
Sample
1278 mothers distributed among the schools were asked for informed consent, 833 (65.1%) accepted participation, in all those cases; their daughters fulfilled the questionnaire in the school and were included in the analysis. Eighty percent of the adolescents lived with both parents and their socioeconomic status was similar to that occurring in Spain in 2010. Most of the parents (82.5%, 95% CI: 79.9-85.1%) were Spanish in origin and 11.3% from South America. Over 85% of the girls were born in Spain (Table 1).
Adolescents’ concerns and attitudes towards social and health problems
Among the social problems that girls were concerned about, school and sport accidents were the least rated, while those more severe or with higher media impact were of highest concern: road traffic accidents and terrorist attacks (Table 2). Concerns about health problems were diverse, being the weight problems the most rated (Table 2), with 78.5% (95% CI: 75.7-81.3%) of the girls being worried about it. Table 1 Characteristics of the study participants N
%
Spain
716
86.0
Other
116
14
Country of birth
Current family status Living with both parents
658
79.0
Parents divorced/separated
138
16.5
Father or mother widow
25
3.0
Other
12
1.4
117
0.14
Religious beliefs Practising Occasional practising
133
16.0
Non-practising
303
36.4
Non-believer
215
25.8
No answer
65
7.8
Father (%)
Mother (%)
52 (6.9)
12 (1.6)
187 (24.7)
117 (15.5)
30 (4.0)
87 (11.5)
Admin./self-employed
171 (22.6)
100 (13.2)
Qualified technician
176 (23.5)
97 (12.8)
Parents occupation Unemployed Undergraduate/director >10 Postgraduate/director
